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The feasibility of HIV prevention studies for men who have sex with men in Malawi

The feasibility of HIV prevention studies for men who have sex with men in Malawi. Stefan Baral, MD, MPH, FRCPC Key Populations Program, Center for Public Health and Human Rights Department of Epidemiology Johns Hopkins Bloomberg School of Public Health July 1, 2013. MOAC0105. Outline.

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The feasibility of HIV prevention studies for men who have sex with men in Malawi

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  1. The feasibility of HIV prevention studies for men who have sex with men in Malawi

    Stefan Baral, MD, MPH, FRCPC Key Populations Program, Center for Public Health and Human Rights Department of Epidemiology Johns Hopkins Bloomberg School of Public Health July 1, 2013 MOAC0105
  2. Outline HIV among MSM Epidemiology Prevention Sciences Malawi Context for MSM Methods Use of respondent driven sampling for accrual into cohort Results Conclusions
  3. Global HIV prevalence among MSM, 2007-2011 Source: Beyrer, Baral, van Griensven, Goodreau, Chariyalertsak, Wirtz, Brookmeyer, The Lancet, 2012
  4. HIV Prevalence among MSM in Africa 6.2% (267) 4.9% (1,778) 4.4% (90) Egypt 21.5% (463) 21.8% (501) 9.3% (713) Tunisia Morocco 7.3% (406) 5.7% (259) 5.9% (262) 25.0% (N/A) 13.4% (1,125) Senegal Sudan 17.2% (1,291) Nigeria 24.6% (285) 13.3% (215) Ghana The Gambia 13.2% (306) Legend 19.0% (563) Uganda Kenya Tanzania 12.3% (509) 21.4% (201) 2002 2003 12.4% (218) Malawi 2004 40.7% (285) 19.7% (117) 2005 Namibia 28.9% (249) 2006 Botswana 2007 25.0% (200) Soweto 2009 2008 2010 10.6% (538) Cape Town (Township) 2011 Cape Town Modified From : van Griensven, Baral, et al. The Global Epidemic of HIV Infection among Men who have Sex with Men. Curr Opinion on HIV/AIDS, 2009
  5. HIV Prevention Studies among MSM Source: Sullivan, Sanchez, Coates, et al., The Lancet, 2012
  6. MSM in Malawi Limited Disclosure of Same Sex Practices to Family or Health Care Workers (~15%) Challenging for traditional approaches to trial recruitment
  7. Study Objective Assess the feasibility of: Accruing participants into a cohort using respondent driven sampling of MSM in Blantyre Characterize unbiased estimates of the epidemiology of HIV and syphilis as well as the associations of prevalent HIV and syphilis infections among MSM Using a community-driven peer-based model to sustain retention of MSM over 12 months Achieve >= 90% Retention of MSM over 12 months Assess the incidence of HIV among MSM in Blantyre Provide training to health care centers in Malawi to be more clinically and culturally competent in addressing the needs of MSM in Blantyre
  8. Study Methods Baseline Inclusion Criteria 18+ men who report having anal sex with another man in the previous 12 months Accrual 330 recruited via respondent-driven sampling Behavioral Survey Translated into Chichewa with modules representing multiple levels of HIV risk Biological Testing HIV and syphilis Malawi National Guidelines with pre- and post-test counseling
  9. Study Methods Follow Up Inclusion Criteria Planning on remaining in Blantyre for following 12 months Willing to provide mobile number and pseudonym HIV-uninfected participants Accrual Offered accrual during second RDS-related study visit Accrued until 100 in the cohort Visits 0, 3, 6, 9, 12 Months Intervention Health Sector Intervention Enhanced Peer Education Services
  10. Health Sector Intervention Together with Fenway Health Institute Two-day training, December 2011 Target Nurses and physicians from private and government clinics Curriculum Sexual history taking, anal health, mental health, risk reduction counseling
  11. Peer Educators 10 Peer Educators Trained Diversity in sexual orientation, identity, demographics Provided information on prevention and trained clinics, condoms & condom compatible lubricants Provided monthly stipend Each linked to 10 matched participants to ensure retention matched according to sociodemographic characteristics and participant choice
  12. Results Accrual for RDS took approximately 3 months Coupon return: 48%; maximum of 19 waves reached Approximately 50% of HIV-uninfected MSM were successfully accrued into cohort RDS Recruitment Diagram (N= 338)
  13. Results
  14. Results Retention at one year was 99% (99/100) with 7 incident HIV infections Approximate HIV incidence of 7.1 (95%CI 2.0-12.0%) Increased utilization of trained health providers, peer educator visits, and condoms and condom compatible lubricants Study site is being utilized frequently for HIV prevention needs among study participants
  15. Conclusions Scientific Agenda Appropriate population for HIV prevention strategies High HIV incidence Feasibility of retention of hidden population by leveraging: Existing community-based organizations and social networks evaluating community-driven HIV prevention services for MSM in Malawi. HIV Prevention 2.0 includes: Combining community-driven HIV prevention services with novel HIV prevention approaches such as: Active linkage to care using point of care approaches Engaging the Continuum of HIV Care from being unaware of HIV infection through to viral suppression for those treatment eligible Feasibility of ART pre-exposure prophylaxis Rectal microbicides Development Agenda There is a group of men who are at high risk for HIV acquisition and transmission that are currently underserved
  16. Lilongwe, 2012
  17. Acknowledgements Center for Development of People (CEDEP) Gift Trapence Dunker Kamba Center for Public Health and Human Rights Chris Beyrer, Andrea Wirtz (Co-I), Susanne Stromdahl, Mark Berry R2P Deanna Kerrigan, Caitlin Kennedy Malawi College of Medicine Eric Umar (PI), Rajab Mkakosya (Lab PI), Vincent Jumbe Foundation for AIDS Research (amfAR) Health Sector Intervention Kevin Frost, Chris Collins, Owen Ryan, Kent Klindera, Michael Cowing USAID Sarah Sandison, Delivette Castor, Henry Cauley, Alison Cheng, Laurent Kapesa, Beth Deutsch
  18. The USAID | Project SEARCH, Task Order No.2, is funded by the U.S. Agency for International Development under Contract No. GHH-I-00-07-00032-00, beginning September 30, 2008, and supported by the President’s Emergency Plan for AIDS Relief. The Research to Prevention (R2P) Project is led by the Johns Hopkins Center for Global Health and managed by the Johns Hopkins Bloomberg School of Public Health Center for Communication Programs (CCP).
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